Sexual Dysfunction In many individuals with sexual

CHAP 15 dysfunctions, the time of onset may indicate

different etiologies and interventions.
Sexual dysfunctions include delayed
ejaculation, erectile disorder, female Lifelong refers to a sexual problem that has
orgasmic disorder, female sexual been present from the first sexual
interest/arousal disorder, genito-pelvic experience.
pain/penetration disorder, male
hypoactive sexual desire disorder, Acquired and applied to sexual
premature (early) ejaculation, dysfunctions that develop after a period of
substance/medication-induced sexual relatively normal sexual function.
dysfunction, another specified sexual
dysfunction, and unspecified sexual Generalized refers to sexual difficulties that
dysfunction. are not limited to certain types of
stimulation, situations, or partners.
Sexual dysfunctions are a heterogeneous
group of disorders that are typically Situational refers to sexual difficulties that
characterized by a clinically significant only occur with certain types of stimulation,
disturbance in a person’s ability to situations, or partners.
respond sexually or to experience sexual
pleasure. In addition to the lifelong/acquired and
generalized/situational subtypes, several
An individual may have several sexual factors must be considered during the
dysfunctions at the same time. In such assessment of sexual dysfunction, given
cases, all the dysfunctions should be that they may be relevant to etiology or
diagnosed. treatment and may contribute, to varying
degrees, across individuals:
Clinical judgment should be used to
determine if the sexual difficulties are the 1) partner factors (e.g.,partner’s sexual
result of inadequate sexual stimulation; problems; partner’s health status);
in these cases, there may still be a need
for care, but a diagnosis of a sexual 2) relationship factors (e.g., poor
dysfunction would not be made. communication; discrepancies in desire for
sexual activity);
These cases may include but are not limited
to, conditions in which a lack of knowledge 3) individual vulnerability factors (e.g.,
about effective stimulation prevents the poor body image; history of sexual or
experience of arousal or orgasm. emotional abuse), psychiatric comorbidity
(e.g., depression, anxiety), or stressors
Subtypes are used to designate the onset of (e.g., job loss, bereavement);
the difficulty.
4) cultural or religious factors Delayed ejaculation is associated with
(e.g.,inhibitions related to prohibitions highly frequent masturbation, the use of
against sexual activity or pleasure; attitudes masturbation techniques not easily
toward sexuality); and duplicated by a partner, and marked
disparities between sexual fantasies
5) medical factors relevant to prognosis, during masturbation and the reality of sex
course, or treatment. with a partner.

Clinical judgment about the diagnosis of Males with delayed ejaculation typically
sexual dysfunction should take into report less coital activity, higher levels of
consideration cultural factors that may relationship distress, sexual
influence expectations or engender dissatisfaction, lower subjective arousal,
prohibitions about the experience of anxiety about their sexual performance,
sexual pleasure. and general health issues than sexually
functional men.
Aging and relationship duration may be
associated with a normative decrease in The following factors are important to
sexual response. consider in the assessment of delayed
ejaculation:
Sexual response has a requisite biological
underpinning, yet is usually experienced in 1) partner factors (e.g., partner’s sexual
an intrapersonal, interpersonal, and cultural problems or health);
context.
2) relationship factors (e.g., poor
Thus, sexual function involves a complex communication, discrepancies in desire for
interaction among biological, sociocultural, sexual activity);
and psychological factors.
3) individual vulnerability factors (e.g.,
Delayed Ejaculation - Associated hypoactive sexual desire), psychiatric
Features comorbidity (e.g., depression, anxiety), or
stressors such as job loss or stress;
The man and his partner may report
prolonged thrusting to achieve orgasm 4) cultural/religious factors (e.g.,
to the point of exhaustion or genital inhibitions related to prohibitions against
discomfort and sometimes even injury to sexual activity; attitudes toward sexuality);
himself and/or his partner before finally
ceasing. 5) medical factors, particularly
hypogonadism or neurological disorders
Some males may report avoiding sexual (e.g., multiple sclerosis, diabetic
activity because of a repetitive pattern of neuropathy); and
difficult ejaculating.
6) use of substances or medications that
might inhibit ejaculation (e.g., use of
serotonergic drugs).
Delayed Ejaculation - Development and and sleep apnea, as well as alcohol abuse,
Course bowel dysfunction, cannabis use, and
environmental factors, may be associated
The prevalence of delayed ejaculation with delayed ejaculation.
increases with age.
Age-related loss of the fast-conducting
As males age, they are more likely to have peripheral sensory nerves and age-related
progressively more of the following changes decreased sex steroid secretion may be
in ejaculatory function, including, but not associated with an increase in delayed
limited to, reduced ejaculatory volume, ejaculation in males as they age.
force, and sensation, and increased
“refractory time.” Reduced androgen levels with age may
also be associated with delayed ejaculation.
Refractory latency increases for male's
secondary to surgical, medical, and Erectile Disorder - Associated Features
pharmaceutical complications, as well as
aging. Many males with erectile disorder may have
low self-esteem, low self confidence, and a
Delayed Ejaculation - Prevalence decreased sense of masculinity, and may
experience a depressed mood.
The prevalence of delayed ejaculation in the
United States is estimated at 1%–5% but Erectile dysfunction is also strongly
has ranged as high as 11% in associated with feelings of guilt, self-
international studies. blame, sense of failure, anger, and
concern about disappointing one’s
However, variations in syndrome definitions partner. Fear and/or avoidance of future
across studies may have contributed to sexual encounters may occur.
differences in the prevalence of the DSM-5
disorder. The following factors are important to
consider in
Delayed Ejaculation - Risk and the assessment of erectile disorder:
Prognostic Factors
1) partner factors (e.g., partner’s sexual
Numerous medical conditions may lead to problems or health);
delayed ejaculation, including procedures
that disrupt sympathetic or somatic 2) relationship factors (e.g., poor
innervation to the genital region such as communication, discrepancies in desire for
radical prostatectomy for cancer sexual activity);
treatment.
3) individual vulnerability factors (e.g.,
Neurological and endocrine disorders, hypoactive sexual desire), psychiatric
including spinal cord injury, stroke, multiple comorbidity (e.g., depression, anxiety), or
sclerosis, pelvic-region surgery, severe stressors such as job loss or stress;
diabetes, epilepsy, hormonal abnormalities,
4) cultural/religious factors (e.g., tobacco, lack of physical exercise,
inhibitions related to prohibitions against diabetes, and decreased desire.
sexual activity; attitudes toward sexuality);
Erectile Disorder - Prevalence
5) medical factors, particularly surgery
(e.g., transurethral resection of the The prevalence of lifelong versus acquired
prostate), hypogonadism, or neurological erectile disorder is unknown. There is a
conditions (e.g., multiple sclerosis, diabetic strong age-related increase in both the
neuropathy); and prevalence and incidence of problems with
erection, particularly after age 50 years.
6) use of substances or medications that
might inhibit ejaculation (e.g., use of Rates appear to be lower than 10% in
serotonergic drugs). males younger than 40 years, about 20%–
40% in males in their 60s, and 50%–75% in
Erectile Disorder - Development and males older than 70 years.
Course
In a longitudinal study in Australia, 80% of
Erectile failure on the first sexual attempt is males aged 70 and older experienced
related to having sex with a previously erectile disorder.
unknown partner, concomitant use of
drugs or alcohol, not wanting to have In a review of studies largely from Western
sex and peer pressure. countries, about 20% of males feared
erectile problems on their first sexual
The natural history of lifelong erectile experience, whereas approximately 8%
disorder is unknown. experienced erectile problems that
hindered penetration during their first
Clinical observation supports the sexual experience.
association of lifelong erectile disorder
with psychological factors that are self- Female Orgasmic Disorder - Associated
limiting or responsive to psychological Features
interventions, whereas, as noted above,
acquired erectile disorder is more likely to Overall sexual satisfaction, however, is not
be related to biological factors and strongly correlated with orgasmic
persistent. experience.

The incidence of erectile disorder increases Many women report high levels of sexual
with age. satisfaction despite rarely or never
experiencing orgasm.
Erectile Disorder - Risk and Prognostic
Factors Orgasm difficulties in women often co-occur
with problems related to sexual interest
Course modifiers. Risk factors for acquired and arousal.
erectile dysfunction and, consequently,
erectile disorder include age, smoking
In addition to the subtypes Women show a more variable pattern in age
“lifelong/acquired” and at first orgasm than do men, and women’s
“generalized/situational,” the following reports of having experienced orgasm
five factors must be considered during the increase with age.
assessment and diagnosis of female
orgasmic disorder given that they may be Many women learn to experience orgasm
relevant to etiology or treatment: as they experience a wide variety of
stimulation and acquire more knowledge
1) partner factors (e.g., partner’s sexual about their bodies.
problems, partner’s health status);
Women’s rates of orgasmic consistency
2) relationship factors (e.g., poor (defined as “usually or always”
communication, discrepancies in desire for experiencing orgasm) are higher during
sexual activity); masturbation than during sexual activity
with a partner.
3) individual vulnerability factors (e.g.,
poor body image, history of sexual or Female Orgasmic Disorder - Risk and
emotional abuse), psychiatric comorbidity Prognostic Factors
(e.g., depression, anxiety), or stressors
(e.g., job loss, bereavement); Temperamental factors include negative
cognitions and attitudes about sexuality
4) cultural/religious factors (e.g., and a history of mental disorders.
inhibitions related to prohibitions against
sexual activity; attitudes toward Differences in the propensity for sexual
sexuality); and excitation and sexual inhibition may also
predict the likelihood of developing sexual
5) medical factors relevant to prognosis, problems.
course, or treatment.
Environmental factors include relationship
Female Orgasmic Disorder - difficulties, partner sexual functioning,
Development and Course and developmental history, such as early
relationships with caregivers and
Lifelong female orgasmic disorder childhood stressors.
indicates that orgasm difficulties have
always been present, whereas the Some medical conditions (e.g., diabetes
acquired subtype would be assigned if the mellitus, thyroid dysfunction) can be risk
woman’s orgasm difficulties developed after factors for female sexual interest/arousal
a period of normal orgasmic functioning. disorder.

A woman’s first experience of orgasm can There appears to be a strong influence of

occur any time from the prepubertal period genetic factors on vulnerability to sexual
to well into adulthood. problems in women.
Female Orgasmic Disorder - Prevalence diagnosed with female sexual
interest/arousal disorder.
Reported prevalence rates for orgasm
problems in premenopausal women vary Female Sexual Interest/Arousal Disorder
widely, from 8% to 72%, depending on - Development and Course
multiple factors (e.g., age, cultural
background and context, duration, severity Lifelong female sexual interest/arousal
of symptoms); however, these estimates do disorder suggests that the lack of sexual
not take into account the presence of interest or arousal has been present for
distress. the woman’s entire sexual life.

Only a proportion of women experiencing The acquired subtype would be assigned if

orgasm difficulties also report associated the difficulties with sexual interest or arousal
distress. developed after a period of non-
problematic sexual functioning.
Variations in how symptoms are assessed
(e.g., the duration of symptoms and the Adaptive and normative changes in sexual
recall period) also influence prevalence functioning may result from partner-related,
rates. interpersonal, or personal events and
may be transient.
Internationally, approximately 10% of
women do not experience orgasm However, the persistence of symptoms for
throughout their lifetime. approximately 6 months or more would
constitute a sexual dysfunction.
Female Sexual Interest/Arousal Disorder
- Associated Features Female Sexual Interest/Arousal Disorder
Prevalence
Female sexual interest/arousal disorder is
frequently associated with problems in Approximately 30% of women experience
experiencing orgasm, pain experienced chronic low desire, with approximately half
during sexual activity, infrequent sexual of these experiencing significant partner-
activity, and couple-level discrepancies related distress and a quarter experiencing
in desire. personal distress.

Relationship difficulties, chronic stress, The prevalence of low sexual desire and
and mood disorders are also frequently problems with sexual arousal (with and
associated features of female sexual without associated distress) may vary
interest/arousal disorder. markedly about age, cultural context,
duration of symptoms, and presence of
Unrealistic expectations and norms distress.
regarding the “appropriate” level of sexual
interest or arousal, along with poor sexual
techniques and lack of information about
sexuality, may also be evident in women
Female Sexual Interest/Arousal Disorder It is common for females who have not
- Risk and Prognostic Factors succeeded in having vaginal penetration to
come for treatment only when they wish to
Temperamental factors include negative conceive.
cognitions and attitudes about sexuality and
a history of mental disorders. Many females with genito-pelvic
pain/penetration disorder will experience
Differences in the propensity for sexual associated relationship/marital problems;
excitation and sexual inhibition may also they also often report that the symptoms
predict the likelihood of developing sexual significantly diminish their feelings of
problems. femininity.

Environmental factors include relationship The development and course of genito-

difficulties, partner sexual functioning, and pelvic pain/penetration disorder is unclear.
developmental history, such as early
relationships with caregivers and childhood Because women generally do not seek
stressors. treatment until they experience problems in
sexual functioning, it can, in general, be
Some medical conditions (e.g., diabetes difficult to characterize genito-pelvic
mellitus, thyroid dysfunction) can be risk pain/penetration disorder as lifelong
factors for female sexual interest/arousal (primary) or acquired (secondary).
disorder. There appears to be a strong
influence of genetic factors on vulnerability Genito-Pelvic Pain/Penetration Disorder
to sexual problems in women. Prevalence

Genito-Pelvic Pain/Penetration Disorder The prevalence of genito-pelvic

Associated Features pain/penetration disorder is unknown.

Genito-pelvic pain/penetration disorder However, approximately 10%–28% of

is frequently associated with other sexual females of reproductive age in the United
dysfunctions, particularly reduced sexual States report recurrent pain during
desire and interest (female sexual intercourse.
interest/arousal disorder).
The prevalence of genito-pelvic pain during
Sometimes desire and interest are sexual activities involving vaginal
preserved in sexual situations that are not penetration among lesbian women relative
painful or do not require penetration. to heterosexual women remains uncertain
but may be similar or lower.
Even when individuals with genito-pelvic
pain/penetration disorder report sexual Prevalence rates among other sexual
interest/motivation, there is often minorities, including transgender women,
behavioral avoidance of sexual situations are unknown.
and opportunities.
Genito-Pelvic Pain/Penetration Disorder
Risk and Prognostic Factors Men with hypoactive sexual desire disorder
often report that they no longer initiate
Females with antecedent mood and sexual activity and that they are minimally
anxiety disorders are four times more receptive to a partner’s attempt to initiate.
likely to develop symptoms of genito-pelvic
pain/penetration disorder compared with Sexual activities (e.g., masturbation or
those without these antecedent disorders. partnered sexual activity) may sometimes
occur even in the presence of low sexual
Psychosocial factors (e.g., pain desire.
catastrophizing, pain self-efficacy,
avoidance of pain, negative mood) and Relationship-specific preferences regarding
interpersonal factors (e.g., insecure patterns of sexual initiation must be
attachment, negative partner responses to considered when making a diagnosis of
the pain, sexual motives that focus on male hypoactive sexual desire disorder.
avoiding negative relationship outcomes)
may exacerbate and maintain symptoms. Although men are more likely to initiate
sexual activity, and thus low desire may be
Females with genito-pelvic pain/penetration characterized by a pattern of non-initiation,
disorder are more likely to report a history many men may prefer to have their
of sexual and/or physical abuse, and fear partner initiate sexual activity.
of abuse than females without this disorder,
although not all women with presenting In such situations, the man’s lack of
symptoms have this history. receptivity to a partner’s initiation should be
considered when evaluating low desire.
Females experiencing superficial pain
during vaginal penetration often report the Male Hypoactive Sexual Desire Disorder
onset of the pain after a history of Development and Course
vaginal infections.
Lifelong male hypoactive sexual desire
Even after the infections have resolved and disorder indicates that low or no sexual
there are no known residual physical desire has always been present, whereas
findings, the pain persists. the acquired subtype would be assigned if
the man’s low desire developed after a
Male Hypoactive Sexual Desire Disorder period of normal sexual desire.
Associated Features
There is a normative age-related decline in
Male hypoactive sexual desire disorder is sexual desire.
sometimes associated with erectile and/or
ejaculatory concerns. There is a requirement that low desire
persist for approximately 6 months or
For example, persistent difficulties obtaining more; thus, short-term changes in sexual
an erection may lead a man to lose interest desire should not be diagnosed as male
in sexual activity. hypoactive sexual desire disorder.
The prevalence of low sexual desire in men Male Hypoactive Sexual Desire Disorder
increases with age, from approximately Risk and Prognostic Factors
5.2% prevalence at age 27 years to 18.5%
at age 50 years. Other environmental determinants of low
sexual desire include problematic dyadic
Male Hypoactive Sexual Desire Disorder relationships, reduced attraction toward
Prevalence the partner, living in a long-term
relationship, sexual boredom, and
The prevalence of male hypoactive sexual professional stress.
desire disorder varies depending on country
of origin and method of assessment. Endocrine disorders such as
hyperprolactinemia and hypogonadism
Estimates of prevalence in representative significantly affect sexual desire in men.
samples range from 3% to 17%.
Age is a significant risk factor for low desire
Sexual desire problems are less common in in men.
younger men (ages 16–24), with prevalence
rates between 3% and 14%, compared with It is unclear whether men with low desire
older men (ages 60–74 years), with also have abnormally low levels of
prevalence rates between 16% and 28%. testosterone; however, among
hypogonadal men, low desire is common.
However, a persistent lack of interest in sex,
lasting 6 months or more, affects a smaller Premature (Early) Ejaculation -
proportion of men (6%). Associated Features

Moreover, less than 2% of men report Many males with premature (early)
clinically significant distress associated with ejaculation complain of a sense of lack of
low desire. control over ejaculation and report
apprehension about their anticipated
Studies on help-seeking behavior indicate inability to delay ejaculation in future sexual
that only 10.5% of men with sexual encounters.
problems in the previous year sought help.
The following factors may be relevant in the
Mood and anxiety symptoms appear to be evaluation of any sexual dysfunction:
strong predictors of low desire in men.
1) partner factors (e.g., partner’s sexual
Up to half of men with a history of problems, partner’s health status);
psychiatric symptoms may have moderate
or severe loss of desire, compared with only 2) individual vulnerability factors (e.g.,
15% of those without such a history. history of sexual or emotional abuse),
psychiatric comorbidity (e.g., depression,
Alcohol use may increase the occurrence anxiety), and stressors (e.g., job loss,
of low desire. bereavement);
3) relationship factors (e.g., poor Premature (Early) Ejaculation
communication, discrepancies in desire for Prevalence
sexual activity);
Estimates of the prevalence of premature
4)cultural/religious factors (e.g., lack of (early) ejaculation vary widely depending on
privacy, inhibitions related to prohibitions the definition utilized.
against sexual activity; attitudes toward
sexuality); and Internationally, a prevalence range of 8%–
30% has been reported across all ages,
5)medical factors relevant to prognosis, with even lower and higher rates in other
course, or treatment. studies.

Lifelong premature (early) ejaculation Prevalence of premature (early) ejaculation

starts during a male’s initial sexual may increase with age.
experiences and persists thereafter.
Premature (Early) Ejaculation - Risk and
Some males may experience premature Prognostic Factors
(early) ejaculation during their initial sexual
encounters but gain ejaculatory control over Premature (early) ejaculation may be more
time. common in males with anxiety disorders,
especially social anxiety disorder.
It is the persistence of ejaculatory problems
for longer than 6 months that determines There is a moderate genetic contribution to
the diagnosis of premature (early) lifelong premature (early) ejaculation.
ejaculation.
Thyroid disease, prostatitis, and drug
Premature (Early) Ejaculation - withdrawal are associated with acquired
Development and Course premature (early) ejaculation.

In contrast, some males develop the Premature (early) ejaculation may be

disorder after a period of having a normal associated with dopamine transporter
ejaculatory latency, known as acquired gene polymorphism or serotonin
premature (early) ejaculation. transporter gene polymorphism.

There is far less known about acquired Positron emission tomography measures of
premature (early) ejaculation than about regional cerebral blood flow during
lifelong premature (early) ejaculation. ejaculation have shown primary activation in
the mesocephalic transition zone, including
The acquired form likely has a later onset, the ventral tegmental area.
usually appearing during or after the
fourth decade of life.

Lifelong is relatively stable throughout life.

Gender Dysphoria Gender identity is a category of social
CHAP 16 identity and refers to an individual’s
identification as male, female, some
In this chapter, sex and sexuality refer to the category in between (i.e., gender fluid), or a
biological indicators of male and female category other than male or female
(understood in the context of reproductive (i.e.,gender neutral).
capacity), such as sex chromosomes,
gonads, sex hormones, and non There has been a proliferation of gender
ambiguous internal and external identities in recent years.
genitalia.
Gender dysphoria as a general descriptive
Disorders of sex development or differences term refers to the distress that may
of sex development (DSDs) included the accompany the incongruence between
historical terms hermaphroditism and one’s experienced or expressed gender
pseudohermaphroditism. and one’s assigned gender. However, it is
more specifically defined when used as a
Gender is used to denote the public, diagnostic category.
sociocultural (and usually legally
recognized) lived role as boy or girl, man Transgender refers to the broad spectrum
or woman, or other gender. of individuals whose gender identity is
different from their birth-assigned gender.
Biological factors are seen as contributing,
in interaction with social and psychological Cisgender describes individuals whose
factors, to gender development. gender expression is congruent with their
birth-assigned gender (also
Gender assignment refers to the nontransgender). Transsexual, a historic
assignment as male or female. term, denotes an individual who seeks, is
undergoing,
This occurs usually at birth based on
phenotypic sex and, thereby, yields the or has undergone a social transition from
birth-assigned gender,historically referred to male to female or female to male, which in
as “biological sex” or, more recently, “natal many, but not all, cases also involves a
gender”. somatic transition by gender-affirming
hormone treatment and genital, breast, or
Gender reassignment denotes an official other gender affirming surgery (historically
(and sometimes legal) change of gender. referred to as sex reassignment
surgery)
Gender-affirming treatments are medical
procedures (hormones or surgeries or Gender Dysphoria - Associated Features
both) that aim to align an individual’s
physical characteristics with their They sometimes bind their genitals to make
experienced gender erections less visible.Individuals assigned
female at birth may bind their breasts,
walk with a stoop, or use loose sweaters Gender Dysphoria - Development and
to make breasts less visible. Course

Increasingly, adolescents request or may Young children are less likely than older
obtain without medical prescription and children, adolescents, and adults to express
supervision, drugs that suppress the extreme and persistent anatomic dysphoria.
production of gonadal steroids (e.g.,
gonadotropin-releasing hormone [GnRH] In adolescents and adults, incongruence
agonists) or that block gonadal hormone between experienced gender and assigned
actions (e.g., spironolactone) gender is a central feature of the diagnosis.
Factors related to distress and impairment
Older adolescents, when sexually active, also vary with age.
often do not show or allow partners to
touch their sexual organs. The onset of gender nonconforming
behaviors is usually between ages 2 and
For adults with an aversion toward their 4 years.
genitals, sexual activity is constrained by
the preference that their genitals not be This corresponds to the developmental time
seen or touched by their partners. in which most children begin expressing
gendered behaviors and interests.
Adolescents and adults with gender
dysphoria before gender-affirming Some prepubescent children expressing a
treatment and legal gender change are at desire to be another gender will not seek
increased risk for mental health gender-affirming somatic treatments when
problems including suicidal ideation, they reach puberty.
suicide attempts, and suicides.
Studies have shown a high incidence of
sexual attraction to those of the individual’s
Gender Dysphoria - Prevalence birth-assigned gender, regardless of the
trajectory of the prepubescent child’s
There are no large-scale population studies gender dysphoria.
of gender dysphoria.
Late-onset or pubertal/postpubertal-onset
Based on gender-affirming treatment– gender dysphoria occurs around puberty
seeking populations, the prevalence of or even much later in life.
gender dysphoria diagnosis across
populations has been assessed to Some of these individuals report having had
be less than 1/1,000 (i.e., < 0.1%) for both a desire to be of another gender in
individuals assigned male at birth and childhood that was not expressed verbally
individuals assigned female at birth. to others or had gender-nonconforming
behavior that did not meet the full criteria for
gender dysphoria in childhood
Gender Dysphoria - Risk and Prognostic
Factors

A predisposing factor under consideration,

especially in individuals with postpubertal-
onset gender dysphoria (adolescence,
adulthood), includes a history of
transvestism that may develop into
autogynephilia (i.e., sexual arousal
associated with the thought or image of
oneself as a woman).

Individuals assigned male at birth with

gender dysphoria without a DSD (in both
childhood and adolescence) more
commonly have older brothers when
compared with cisgender males.

In gender dysphoria associated with a DSD,

the likelihood of later gender dysphoria is
increased if prenatal production and
utilization (via receptor sensitivity) of
androgens are grossly variant relative
to what is usually seen in individuals with
the same assigned gender.